Some patients may have a competing diagnosis that requires antibiotics at the same time as the denominator pharyngitis diagnosis. In this case, the patient counts as a numerator miss because the physician would not do a strep test before prescribing an antibiotic.​ Proposed Solution: Add a denominator exclusion for competing diagnosis at the same encounter as the pharyngitis diagnosis or in the 3 days after the pharyngitis diagnosis.

Final Recommendation: Add a denominator exclusion for competing diagnosis at the same encounter as the pharyngitis diagnosis or in the 3 days after the pharyngitis diagnosis.   ( "Encounter with Pharyngitis or Tonsillitis" EncounterWithPharyngitis with ["Diagnosis": "Competing Conditions for Respiratory Conditions"] CompetingCondition such that CompetingCondition.prevalencePeriod starts 3 days or less after day of start of EncounterWithPharyngitis.ValidEncounter.relevantPeriod return EncounterWithPharyngitis.ValidEncounter   ( "Encounter with Pharyngitis or Tonsillitis" EncounterWithPharyngitis with ["Diagnosis": "Competing Conditions for Respiratory Conditions"] CompetingCondition such that CompetingCondition.prevalencePeriod starts 3 days or less after day of start of EncounterWithPharyngitis.ValidEncounter.relevantPeriod return EncounterWithPharyngitis.ValidEncounter ​   Rationale: A competing diagnosis exclusion that occurs at the same encounter or in the 3 days after the pharyngitis diagnosis will ensure the patient did not have another diagnosis for which it was appropriate to prescribe an antibiotic. ​